Upper and Midfacial Rejuvenation in the Non-Caucasian Face

Home , Canthus, Epicanthoplasty, Orbital septum, Tarsus (eyelids)

Author's personal copy Upper and Midfacial Rejuvenation in the Non-Caucasian Face

Rami K. Batniji, MDa,b,*, Stephen W. Perkins, MDc,d

KEYWORDS Endoscopic brow lift Botulinum toxin Filler augmentation Midface lift Lower lid blepharoplasty Upper blepharoplasty

In the nineteenth century, Johann Friedrich Blu- location of the eyebrow apex in Asian and white menbach popularized the term ‘‘Caucasian’’ to women. Their findings suggested that neither the describe a distinct group of people from the Cau- ethnicity of the models nor the ethnicity of the casus region with specific craniofacial features. volunteers who analyzed the eyebrow position Although the Caucasus region lies between had a significant role in determining the ideal Europe and Asia and includes Russia, Georgia, eyebrow position. A survey of plastic surgeons Armenia, Azerbaijan, and Iran, the term Caucasian and cosmetologists regarding eyebrow shape in has since been used to describe those individuals women by Freund and Nolan4 found that a medial of European origin. Although age-related changes eyebrow at the level of the supraorbital rim was have some similarities between Caucasians and ideal and that brow lifting techniques tend to non-Caucasians, there are also some distinct elevate the medial eyebrow above this level. differences. In this paper, the authors discuss Increasing eyebrow height with age has been treatment options, surgical and nonsurgical, for previously reported, and this phenomenon has rejuvenation of the upper face and midface, been attributed to habitually contracting the fron- including the periorbital region. For the purposes talis muscle. Therefore, an overly elevated brow of this paper, the term non-Caucasian includes may not only result in a surprised appearance African American, Middle Eastern, and Asian but also impart an aged countenance.5 ethnicities. During the evaluation of the upper eyelid, the forehead should be assessed for ptosis, as this may confound the diagnosis of upper eyelid dermatochalasis. The surgeon should evaluate the FACIAL ANALYSIS upper eyelid to rule out the contribution of blephar- The Upper Third of the Face optosis. The position of the upper eyelid should The ideal eyebrow shape was defined as an arch ideally rest at the level of the superior limbus. If where the brow apex terminates above the lateral unilateral blepharoptosis is identified, the surgeon limbus of the iris, with the medial and lateral ends must rule out blepharoptosis in the contralateral of the brow at the same horizontal level.1 This defi- eye, as Herring’s Law may apply in this situation. nition has been further refined to provide a frame- The Asian upper eyelid has several distinct work for the analysis of the upper third of the face anatomic characteristics including low, poorly and subsequent treatment options for forehead defined or absent eyelid crease, narrow palpebral rejuvenation.2 Biller and Kim3 studied the ideal fissure, and/or epicanthal fold.6

a Batniji Facial Plastic Surgery, 361 Hospital Road, Suite #329, Newport Beach, CA 92663, USA b Department of Plastic Surgery, Hoag Hospital, Newport Beach, CA, USA c Meridian Plastic Surgeons, 170 West 106th Street, Indianapolis, IN 46290, USA d Indiana University School of Medicine, Department of Otolaryngology, Indianapolis, IN, USA * Corresponding author. E-mail address: [email protected] (R.K. Batniji).

Facial Plast Surg Clin N Am 18 (2010) 19–33 doi:10.1016/j.fsc.2009.11.015

of lower eyelid skin).8 In addition, the orbital septum weakens with age leading to steatoblepharon (pseudoherniation of orbital fat).9 Orbicularis oculi muscle hypertrophy is also associated with age-related changes of the upper and lower eyelid complex.10 The tear trough is also known as the nasojugal groove and is defined as the natural depression extending inferolaterally from the medial canthus to approximately the midpupillary line.11 A hollow- ness may be present lateral to the midpupillary line and parallel to the infraorbital rim; this has been referred to by various names, including the lid/ cheek junction. Various anatomic explanations Fig. 1. The trichophytic incision is approximately 4 cm for the tear trough deformity have been provided in length and is made at the midline following the natural irregular contour of the hairline. Laterally on in the literature, including an attachment of orbital each side a 3- to 4-cm incision is made 2 cm posterior septum to arcus marginalis at the level of the to the temporal hairline recession at a location demar- orbital rim, a gap between the levator labii superio- cated by the lateral canthus and temporal line. ris alaeque nasi muscle and the orbicularis oculi muscle, and loss of facial fat in the tear trough or pseudoherniation of fat superior to the tear trough. The Lower Lid/Midface Complex The tear trough and lid/cheek junction occur inferior to the orbital rim and arcus marginalis. Evaluation of lower eyelid position and laxity is an essential part of the examination. The ideal position of the lower eyelid margin is at the inferior limbus.7 A TREATMENT OPTIONS snap test and lid distraction test are key compo- Brow/Forehead nents to the evaluation of lower eyelid laxity. A Nonsurgical options for brow/forehead snap test is performed by grasping the lower eyelid There are several nonsurgical options available for and pulling it away from the globe. When the eyelid is the rejuvenation of the brow/forehead, including released, the eyelid returns to its normal position neuromodulators, dermal fillers, and autologous quickly; however, in a patient with decreased lower fat grafting. For example, Lambros reported volu- eyelid tone, the eyelid returns to its normal position mizing the brow with hyaluronic acid fillers to more slowly. The lid distraction test is performed give more youthful appearance to the brow/perior- by grasping the lower eyelid with the thumb and bital region.12 index finger; movement of the lid margin greater than 10 mm demonstrates poor eyelid tone and an Surgical options and technique for brow/ eyelid tightening procedure is indicated. A Schirmer forehead test is indicated if there is concern about dry eye Many techniques for surgical rejuvenation of the syndrome. Progressive loss of elastic fibers and upper third of the face have been described in collagen organization lead to dermatochalasis the literature. Although the open technique via (loss of skin elasticity and subsequent excess laxity a coronal or trichophytic approach has been the

Fig. 2. (A) The Ramirez EndoForehead parietal elevator (Snowden Pencer, Tucker, GA) is used to elevate the forehead and temporal skin in a subgaleal plane. (B) The elevation is continued approximately 5 cm posterior to the incision sites. Author's personal copy Upper and Midfacial Rejuvenation 21

Fig. 3. (A) A custom-made curved elevator is positioned into the temporal region through the lateral incision to divide the conjoint tendon. (B) Dissection of this temporal region is performed down to an area slightly superior to the zygomatic arch and lateral canthus. standard with which all other techniques have of the deep temporal fascia, and the conjoint been compared, our preferred method for surgical tendon is then divided (Fig. 3). Dissection of this rejuvenation of the brow is the endoscopic brow temporal region is performed down to an area lift. Botulinum toxin injected into the corrugator slightly superior to the zygomatic arch and lateral supercilii and procerus muscles at least 2 weeks canthus. The frontal branch of the facial nerve is before endoscopic brow lift. The combination of protected because the plane of dissection is chemical ablation of the depressor muscles with between the temporoparietal fascia and the super- botulinum toxin A and myotomy of the depressor ficial layer of the deep temporal fascia. Following muscles during the endoscopic forehead lift acts this, elevation is made in a subperiosteal plane synergistically not only to maintain the elevated down to a level of 2 cm above the supraorbital rim forehead position but also to treat the nasoglabel- (Fig. 4) and the arcus marginalis is then elevated. lar furrows. The addition of botulinum toxin may Arcus marginalis elevation is performed with the also lessen the chance of return of depressor nondominant hand functioning as a guide to the muscle function compared with myotomy or level of the supraorbital rim and the location of the myectomy alone. supraorbital foramina (Fig. 5). This elevation is per- One noticeable effect of the endoscopic brow lift formed in the region of the glabella down to the na- is an elevation of the hairline. Although this is an sion. Once the arcus marginalis is elevated, an acceptable result for most patients, persons who endoscope is used to provide visualization; and have high hairlines (greater than 5 to 6 cm) may the conjoint tendon is further divided with curved not wish to move the hairline more posterior. We endoscopic scissors (Accurate Surgical & Scien- perform a technique combining a short 3- to 4-cm tific Instruments Corp, Westbury, NY) down to the trichophytic incision with endoscopic equipment level of the sentinel vein (Fig. 6). Care is then taken to lift the forehead in patients who present with to identify and preserve the supraorbital brow ptosis and high hairlines.13 This technique includes a trichophytic incision that is approximately 4 cm in length and is made at the midline following the natural irregular frontal hairline contour in a scalloped fashion. Laterally, on each side, a 3- to 4-cm vertical incision is made 2 cm posterior to the temporal hairline recession at a location demarcated by the lateral canthus and temporal line (Fig. 1). Initially, flap elevation is made in a subgaleal plane (Fig. 2). The elevation is performed approximately 5 cm posterior to the incision sites; the posterior elevation not only minimizes the development of scalp rolls but also mobilizes the posterior flap, allowing for closure of the trichophytic incision without elevating the hairline. Fig. 4. The Daniel EndoForehead elevator (Snowden The temporal region is elevated in a plane between Pencer) is used to elevate the brow in a subperiosteal the temporoparietal fascia and the superficial layer plane down to a level 2 cm above the supraorbital rim. Author's personal copy 22 Batniji & Perkins

Fig. 5. (A) The Ramirez EndoForehead A/M dissector (Snowden Pencer) is used to elevate the arcus marginalis at the level of the supraorbital rim. (B–D) The elevation is performed with the nondominant hand functioning as a guide to the level of the supraorbital rim and the location of the supraorbital foramina.

neurovascular bundle (Fig. 7). With a custom-made we perform a lateral myotomy of the orbicularis reusable electrode knife tip, the periosteum is oculi muscle not only to weaken the orbicularis incised in a horizontal direction at the level of the oculi muscle but also to interrupt the innervation supraorbital rim (Fig. 8). Myotomy of the corrugator to the corrugator supercilii muscle. In an effort to supercilii and procerus muscles is performed with camouflage the trichophytic incision, we not only the electrode knife tip. Because the motor nerve bevel the incision but also de-epithelialize the to the corrugator supercilii muscle runs within the posterior flap. A 2- to 3-mm strip of epidermis substance of the lateral orbicularis oculi muscle, from the posterior flap is excised (Fig. 9). The anterior flap of the trichophytic incision is lifted up, and vertical incisions are made through the anterior flap. Staples are placed at these positions to approximate the anterior and posterior flaps. The excess skin and soft tissue from the anterior flap are then excised in a beveled manner; the bevel is directed from posterior to anterior (Fig. 10). The staples are then removed and hemostasis is achieved with bipolar electrocautery. Fixation with sutures via bone tunnels of the outer cortex of the skull is performed. The bone tunnels are made with the Browlift Bone Bridge system and drill bit with a 2-mm diameter and 25-mm guard (Med- tronic Xomed Surgical Products, Jacksonville, FL). Two bone tunnels are created at the tricho- Fig. 6. The conjoint tendon is divided with curved endoscopic scissors (Accurate Surgical and Scientific phytic incision site in a horizontal direction, Instruments Corp). This aspect of the procedure is per- whereas bone tunnels are created in the vertical formed under visualization using a 30-degree endo- direction at the lateral incisions (Fig. 11). Using scope, which is placed through the lateral incision. the drill bit with a 25-mm guard, there have been Author's personal copy Upper and Midfacial Rejuvenation 23

Fig. 7. (A) The subperiosteal elevation is completed at the level of the supraorbital rim using the Isse elevator. (B) The trichophytic incision provides easy access to the level of the supraorbital rim despite the high anterior hairline and double convexity of the forehead. no instances of cerebrospinal fluid leaks or other the trichophytic incision is well camouflaged intracranial complications. If significant bleeding (Fig. 14). is encountered from the bone tunnel site, hemostasis is achieved with Bone Wax (Ethicon, Upper Eyelid Somerville, NJ), and new bone tunnels are created. A 2-0 polyglactin suture (Vicryl) is used for fixation Treatment of the non-Caucasian upper eyelid from the bone tunnel to the galea and subcuta- depends on several factors, of which ethnicity is neous tissue of the anterior flap to achieve lifting paramount. Is the non-Caucasian individual Asian, of the medial forehead at the trichophytic incision Middle Eastern, or African American? Within the site. Very minimal lifting is performed medially so Asian population, there are distinct differences in that the medial brow may remain at the level of perceived beauty and motivation for rejuvenation of the upper eyelid based on culture and whether the supraorbtial rim. The lateral forehead is lifted 14 with the suture from the bone tunnel to the galea that patient is Korean, Chinese, or Japanese. If and the subcutaneous tissue at the most anterior a natural crease is present in the aging Asian upper aspect of the lateral incision on both sides eyelid, volume enhancement and conservative (Fig. 12). This suture not only lifts the lateral fore- excision of excess skin would benefit the patient, head but also reapproximates the edges of the whereas a patient who has undergone a previous lateral incision. The lateral incision is closed with procedure and who has a surgically created staples. The trichophytic incision is closed in crease may benefit from volume enhancement a layered fashion (Fig. 13). With meticulous closure, alone, and a patient without a crease may benefit from double eyelid surgery. Does the patient have a history of keloid formation? If so, a noninci- sion suture technique for double eyelid surgery may be an option; however, this treatment has a higher relapse rate compared with incision techniques and fixation. Incision techniques have the benefit of addressing the epicanthal fold in the Asian upper eyelid with an epicanthoplasty.15 In the non-Asian, non-Caucasian patient, a tradi- tional upper eyelid blepharoplasty is an excellent option to treat upper eyelid dermatochalasis and steatoblepharon. The preoperative assessment of the patient seeking rejuvenation of the upper and/or lower eyelid complex includes a history to evaluate for systemic disease processes, such Fig. 8. A custom-made reusable electrode knife tip as collagen vascular diseases and Grave disease, (inset shows tip of instrument) is used to incise the dry eye symptoms, and visual acuity changes. It is periosteum at the level of the supraorbital rim and important to delineate whether the changes to the perform myotomy of the procerus, corrugator superci- upper and/or lower lids are related to age-related lii, and orbicularis oculi muscles. changes to the eyelids (dermatochalasis and Author's personal copy 24

Fig. 9. A 2- to 3-mm strip of epidermis from the posterior flap is excised. (A) A scalpel is used to make the incision through the epidermis. (B) Sharp curved scissors are then used to complete the excision of the strip of epidermis. (C) The intact dermis, subcutaneous tissue, and hair follicles after removal of the epidermal layer.

Fig. 10. Sequential resection of the anterior flap is performed. (A) Vertical incisions are made into the anterior flap, and (B) staples are placed to approximate the anterior and posterior flaps. (C) The excess skin and soft tissue from the anterior flap is then excised in a beveled (posterior to anterior) manner. (D) The result after this skin excision. Author's personal copy Upper and Midfacial Rejuvenation 25

Fig. 11. The Browlift Bone Bridge system (Medtronic Xomed Surgical Products) and drill bit with a 2-mm diameter and a 25-mm guard is used to make a vertically oriented tunnel at the lateral incision (A) and 2 horizontally oriented bone tunnels at the trichophytic incision (B). steatoblepharon) or a manifestation of a systemic obtained if a thyroid disorder is suspected. If any process, such as allergy or an endocrine disorder. unusual history is gleaned from the preoperative For example, a patient with Grave disease may assessment, it may be prudent to obtain an have upper eyelid retraction and exophthalmos, ophthalmologic evaluation before undertaking but the myxedematous state of hypothyroidism blepharoplasty. The limitations of blepharoplasty may mimic dermatochalasis. Therefore, thyroid- and the role of adjuvant procedures must be dis- stimulating hormone (TSH) level should be cussed with the patient. For example, the patient

Fig. 12. (A) A 2-0 polyglactin (Vicryl) suture is used for fixation from the bone tunnel to the anterior flap of the trichophytic incision. (B, C) At the lateral incision, fixation is achieved with suture from the bone tunnel to the most anterior aspect of the lateral incision on both sides. (D) This suture not only lifts the lateral forehead but also reapproximates the edges of the lateral incision. The suture is passed through galea to achieve proper tissue strength for elevation and fixation. Author's personal copy 26 Batniji & Perkins

Fig. 13. (A, B) Meticulous closure of the trichophytic incision is performed with a 3-0 polyglactin suture in an interrupted buried fashion to obtain deep-tissue reapproximation. (C) The assistant further mobilizes the posterior flap to allow closure of the wound without moving the hairline more posteriorly. Further subcutaneous reapproximation is achieved with 4-0 polydioxanone. (D) Following this maneuver, skin closure with proper eversion of the skin edges is achieved with a 5-0 blue polypropylene (Prolene) suture in a running interlocked manner.

seeking periorbital rejuvenation with significant surgery as a difference of 1 to 3 mm (mm) from crow’s feet may benefit from botulinum toxin treat- one eyelid to the next may create noticeable ment, whereas the patient with fine wrinkling, asymmetries. Therefore, the surgical markings crepe paper skin may achieve significant improve- for both upper eyelids are made using a fine tip ment with skin resurfacing. marker and small calipers. With the patient looking up, the supratarsal crease is identified and Surgical technique for the upper eyelid measured from the eyelid margin using small cali- The surgeon must be meticulous in the surgical pers; this denotes the location of the inferior limb markings for upper eyelid blepharoplasty prior to of the surgical marking. This measurement ranges

Fig. 14. Postoperative photograph showing the esthetic result of the trichophytic incision at 12 months. Author's personal copy Upper and Midfacial Rejuvenation 27 from 8 to 12 mm from the lid margin (10–11 mm in women; 8–9 mm in men) (Fig. 15). The inferior limb of the marking is curved gently and parallels the lid margin; the inferior limb of the marking is carried medially to within 1 to 2 mm of the punctum and laterally to the lateral canthus. If the marking is carried along the curve of the eyelid crease lateral to the lateral canthus, the final closure scar line will bring the upper eyelid tissue downward, thus resulting in a hooded appearance. In an effort to avoid this unsightly result, the marking sweeps diagonally upward from the lateral canthus to the lateral eyebrow margin Fig. 16. The marking sweeps diagonally upward from (Fig. 16). This modification of the lateral incision the lateral canthus to the lateral eyebrow margin. makes it easy for women to camouflage the incision with makeup. Medially, the nasal-orbital depression should not be violated as an incision in this area may result in a webbed scar; ending intravenous sedation. Lidocaine 2% with epineph- the incision medially within 1 to 2 mm of the punc- rine (1:50,000) is infiltrated deep to the skin but tum avoids this result. Next, the superior limb of superficial to the orbicularis oculi muscle, thus the surgical marking is made. This is facilitated minimizing the risk of ecchymosis caused by the by using smooth forceps to pinch the excess injection of local anesthesia. Stabilization of amount of upper eyelid skin so that the lashes the skin in the eyelid is paramount to making the roll upward (Fig. 17). The surgeon’s contralateral skin-only incision of the upper eyelid; therefore, hand is used to reposition the eyebrow superiorly an assistant is required to place tension on the to isolate the perceived contribution of brow skin. A round-handled scalpel with a #15 Bard- ptosis from upper eyelid dermatochalasis. Alter- Parker blade is ideal for following the curves of natively, if the patient is undergoing a forehead the surgical markings in the upper eyelid. Once lift at the same time as the upper eyelid blepharo- the skin incision is made, the skin is then sharply plasty, the surgeon may elect to perform the fore- dissected from the underlying orbicularis oculi head lift first and then to measure the appropriate muscle with the blade or dissecting beveled scis- amount of upper eyelid skin excision necessary to sors. The preseptal orbicularis oculi muscle is provide rejuvenation of the upper eyelid complex then evaluated. If it is atrophic or very thin, then while minimizing the risk of lagophthalmos. the muscle need not be excised; however, most Typically, isolated upper eyelid blepharoplasty often, a thin strip of preseptal orbicularis oculi can be performed under local anesthesia with muscle is excised medially, thus exposing the fat compartments. If the muscle is robust, then the excision is performed along the entire length of the eyelid. Attention is then directed to the pseudoherniation of orbital fat. If there is fullness of the upper eyelid, a conservative approach to removal of fat is followed to avoid a hollowed or sunken appearance to the upper eyelid. A small opening is made in the orbital septum overlying the middle and medial fat compartments. Gentle pressure on the globe reveals redundant fat from each compartment. Using Griffiths-Brown forceps, the herniated fat is grasped from its respective compartment; and, unless the patient is under general anesthesia, the fat is infiltrated with local anesthesia to minimize discomfort associated with subse- Fig. 15. The supratarsal crease is identified with the quent electrocautery and excision of the redun- patient looking upward; the supratarsal crease is then measured from the lid margin using small cali- dant fat (Fig. 18). Meticulous hemostasis is of pers. This measurement denotes the location of the utmost importance not only to maintain a clear inferior limb of the surgical marking and ranges operative field but also to minimize the risk of post- between 8 and 12 mm. operative bleeding. Once fat removal from both Author's personal copy 28 Batniji & Perkins

Fig. 17. The superior limb of the surgical marking is made. Smooth forceps are used to pinch the excess amount of upper eyelid skin to roll the eyelashes upward (A). The superior limb is connected with the inferior limb medially and laterally (B).

compartments is completed, bipolar electrocau- blepharoplasty incision closure is then completed tery is used to ensure hemostasis before wound with a running 6-0 blue polypropylene suture in closure. a subcuticular fashion with knots tied at the medial The preferred technique for skin closure is as and lateral aspects of the incision (Fig. 20). follows (Fig. 19): 7-0 blue polypropylene suture is used in an interrupted fashion to reapproximate Lower Eyelid the skin edges. Whereas a 6-0 mild chromic or fast-absorbing gut suture may create an inflamma- Nonsurgical rejuvenation options tory response and subsequent milia, a 7-0 sized Many methods have been used to efface the tear suture rarely produces milia. The upper eyelid trough deformity including fat grafts, injections

Fig. 18. A small opening is made in the orbital septum to access the middle and medial fat compartments. Gentle pressure on the globe demonstrates redundant fat from each compartment; forceps are used to grasp the herniated fat (A). Local anesthesia is infiltrated at the base of the herniated fat (B) and then the base is cauterized (C). Excision of the fat is then performed at the cauterized base. Author's personal copy Upper and Midfacial Rejuvenation 29

hypertrophy, and the presence of pseudoherniation of orbital fat. The incision is 2 mm inferior to the lower eyelid margin and extends from the lower punctum medially to a position 6 mm lateral to the lateral canthus; lateral extension of the incision to this position minimizes rounding of the can- thal angle. Following the skin incision, fine curved scissors are used to dissect through the orbicularis muscle at the lateral aspect of the incision (Fig. 21A). Then, blunt scissors are positioned posterior to the muscle at the lateral aspect of the incision and, with spreading motions of the blunt scissors, the skin-muscle flap is elevated Fig. 19. Skin closure is performed with 7-0 blue poly- off the orbital septum along an avascular plane propylene sutures used in an interrupted fashion to reapproximate the skin edges; the remainder of the (Fig. 21B). The subciliary incision is then skin closure is performed with 6-0 blue polypropylene completed using the scissors in a beveled manner suture in a subcuticular fashion with knots tied at the to ensure the preservation of the pretarsal portion medial and lateral ends. of the orbicularis oculi muscle, thus minimizing the risk of postoperative lower eyelid malposition. with fat or injectable fillers,16 and alloplastic Small openings are made in the orbital septum to implants.17 Treatment of lower eyelid fine lines obtain access to the orbital fat compartments. and wrinkles may be treated with skin resurfacing; Gentle palpation of the globe results in herniation however, the non-Caucasian patient may have of orbital fat through these openings of the orbital a tendency for pigmentation issues after resurfac- septum. Bipolar electrocautery is used to ing. Therefore, pre- and posttreatment of the cauterize the fat pad before excision; before skin with a bleaching agent and/or retinoid must cauterization, local anesthesia is infiltrated into be considered. A nonablative resurfacing proce- the fat pocket to minimize pain. This procedure is dure decreases the risk of pigmentation issues in performed for the lateral, middle, and medial fat the non-Caucasian patient compared with ablative pockets. Gentle palpation of the globe following procedures. Fractionated technologies (both CO2 resection of orbital fat allows for reassessment of and erbium) may have a prominent role in skin orbital fat. A conservative approach to fat resec- resurfacing of non-Caucasian skin. tion is maintained to avoid the creation of a sunken appearance. Then, the skin-muscle flap is reposi- Surgical technique for lower eyelid tioned. If mildly sedated, the patient is asked to Lower eyelid blepharoplasty may be performed via open his or her mouth and look upward; this a transconjunctival or transcutaneous approach. maneuver allows for maximal separation of the Among the transcutaneous approaches, the skin- wound edges and subsequent conservative resec- muscle flap is our preferred technique. The indica- tion of skin and muscle. On the other hand, if the tions for this technique include true vertical excess patient is completely sedated, single-finger pres- of lower eyelid skin, orbicularis oculi muscle sure at the inferomedial portion of the melolabial

Fig. 20. An example of a patient before (A) and after (B) upper eyelid blepharoplasty. This patient underwent concomitant endoscopic browlift and lower eyelid blepharoplasty. Author's personal copy 30 Batniji & Perkins

Fig. 21. (A) The incision is situated 2 mm inferior to the lower eyelid margin and extends from the lower punctum medially to a position 6 mm lateral to the lateral canthus. Following the skin incision, fine curved scissors are used to dissect through the orbicularis muscle at the lateral aspect of the incision, thus exposing the orbital septum. (B) Outwardly beveled blunt scissors are introduced posterior to the muscle at the lateral aspect of the incision and, with spreading motions of the blunt scissors, the skin-muscle flap is effectively elevated off the orbital septum along an avascular plane to the level of the inferior orbital rim inferiorly and the incision superiorly.

Fig. 22. (A) Maximal stretch effect is achieved by single-finger pressure at the inferomedial portion of the melolabial mound. Then, an inferiorly directed segmental cut is made at the lateral canthus to determine the amount of excess skin and muscle to excise. A tacking suture is placed to maintain the position of the skin-muscle flap. (B) The overlapping skin and muscle are excised. Conservative resection decreases the incidence of postoperative lower eyelid malposition. (C) If orbicularis oculi muscle hypertrophy is evident, an additional 1-2 mm strip of muscle is resected to prevent overlapping of muscle and subsequent ridge formation during closure of the subciliary incision. Author's personal copy Upper and Midfacial Rejuvenation 31

Fig. 24. The subciliary incision is closed with 7-0 blue polypropylene suture at the lateral canthus in a simple interrupted fashion; the remainder of the incision is closed with 6-0 mild chromic suture in a running fashion.

mound creates the same maximal stretch effect. Following this maneuver, an inferiorly directed segmental cut is made at the lateral canthus to determine the amount of excess skin to excise (Fig. 22A). A tacking suture is placed to maintain the position of the skin-muscle flap; eyelid scissors are then used to excise the overlapping skin (Fig. 22B). If orbicularis oculi muscle hypertrophy is evident, a 1- to 2-mm strip of muscle is resected to prevent overlapping of the muscle and ridge formation during closure of the subciliary incision (Fig. 22C). Conservative resection of skin and muscle decreases the incidence of postoperative lower eyelid malposition. In addition, suspension of the orbicularis oculi muscle to the periosteum

Fig. 23. Suspension of the orbicularis oculi muscle to the periosteum of the lateral orbital rim at the tubercle with 5-0 polyplyconate (Maxon) maintains proper eyelid position. Fig. 25. The preseptal approach to the transconjunctival blepharoplasty relies on an incision located inferior to the tarsus and not deep to the inferior fornix, thus allowing for a more anterior to posterior approach to the fat pockets. Author's personal copy 32 Batniji & Perkins

Fig. 26. Lower blepharoplasty via transconjunctival approach: (A) preoperatively and (B) postoperatively.

of the lateral orbital rim assists in maintaining suture at the lateral canthus in a simple interrupted proper eyelid position (Fig. 23). If there is evidence fashion; the remainder of the incision is closed with of festoons or malar mounds, an extended lower 6-0 mild chromic suture in a running fashion. eyelid blepharoplasty is performed inferior to the Compared with the transconjunctival approach, infraorbital rim; the redundant orbicularis oculi the transcutaneous method can correct true muscle and/or malar mounds are addressed by vertical excess of lower eyelid skin and orbicularis advancing the entire skin-muscle flap and suborbi- oculi hypertrophy. However, there are specific cularis oculi fat (SOOF) unit superiolaterally.18 indications for the transconjunctival approach.19 Following muscle suspension, the subciliary inci- For example, young patients with excellent elas- sion is closed (Fig. 24) with 7-0 blue polypropylene ticity, presence of hereditary pseudoherniation of

Fig. 27. Fat transposition. A pocket is created posterior to the orbicularis oculi muscle but anterior to the periosteum (A). The medial fat pocket is released from the surrounding orbital septum (B) and subsequently sutured over the infraorbital rim into the previously made pocket with 6-0 polyglycolic acid (Dexon) (C). Author's personal copy Upper and Midfacial Rejuvenation 33 orbital fat, and no evidence of skin excess are 2. Schreiber JE, Singh NK, Klatsky SA. Beauty lies in the ideally suited for the transconjunctival approach. ‘‘eyebrow’’ of the beholder: a public survey of eyebrow In addition, patients with Fitzpatrick skin types aesthetics. Aesthet Surg J 2005;25:348–52. V-VI may benefit from the transconjunctival 3. Biller JA, Kim DW. A contemporary assessment of approach, as the transcutaneous lower eyelid facial aesthetic preferences. Arch Facial Plast Surg blepharoplasty scar may depigment in these 2009;11(2):91–7. patients. The transconjunctival approach results 4. 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New York: Raven access to the fat pockets (Figs. 25 and 26).21 Press; 1995. p. 285–318. Transposition of pedicled orbital fat over the 8. Friedman O. Changes associated with the aging face. orbital rim is an excellent adjunct to lower eyelid Facial Plast Surg Clin North Am 2005;13:371–80. blepharoplasty for patients with a tear trough 9. Rankin BS, Arden RC, Crumley AL. Lower eyelid deformity.22 Fat transposition is performed with blepharoplasty. In: Papel ID, editor. Facial plastic lower eyelid blepharoplasty extending below the and reconstructive surgery. 2nd edition. New York: infraorbital rim. Once the orbital fat from the medial Thieme; 2002. p. 196–207. pocket is isolated from the orbital septum, it is 10. Bernardi C, Dura S, Amata PL. Treatment of orbicu- transposed over the orbital rim and positioned laris oculi muscle hypertrophy in lower lid blepharo- into a pocket posterior to the orbicularis oculi plasty. Aesthetic Plast Surg 1998;5:349–51. muscle and anterior to the periosteum to efface 11. Loeb R. Fat pad sliding and fat grafting for leveling the tear trough deformity. The transposed orbital lid depressions. Clin Plast Surg 1981;8:757–76. fat is then secured to the periosteum using inter- 12. Lambros V. Volumizing the brow with hyaluronic acid rupted 6-0 polyglycolic acid (Dexon) sutures fillers. Aesthet Surg J 2009;29(3):174–9. (Fig. 27). The contour of the orbital fat is then soft- 13. Perkins SW, Batniji RK. Trichophytic endoscopic ened using bipolar electrocautery. The lower forehead-lifting in high hairline patients. Facial Plast eyelid blepharoplasty is then completed as previ- Surg Clin North Am 2006;14:185–93. ously described. 14. Lam SM. Aesthetic strategies for the aging Asian face. Facial Plast Surg Clin North Am 2007;15(3):283–91. 15. Park JI, Park MS. Park Z-epicanthoplasty. Facial SUMMARY Plast Surg Clin North Am 2007;15(3):343–52. 16. Kane MA. 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